Published 4:00 am, Thursday, March 7, 1996

Bucking years of conventional thinking that has led health insurers to discourage emergency room use, a Michigan study published today finds that it can be cheaper to treat minor ailments in the hospital ER than at the doctor's office.

The study of six Michigan hospitals published in the New England Journal of Medicine found that the average cost of treating a patient for a minor ailment in the emergency room was $62, but the marginal cost -- the expense for each additional visit -- was only

$24. This compared to $53 for a first-time visit to a doctor's office.

The average cost of an emergency room visit, regardless of the severity of illness, was $209, while the average charge was $383.

"The simplest way to put it is that it costs very little extra to see these minor problems," said Dr. Robert Williams of the University of Michigan School of Public Health. "If you have a doctor down the street who is willing to see the patient, it might be cheaper during the day. But doctors' offices aren't always open. To keep one open at midnight, on the Fourth of July, would be prohibitive."

In recent years, health insurers have prodded, pushed and bullied their members away from routine emergency room use because of earlier evidence that visits for sore throats or fevers run triple the cost of clinic visits.

Health plans charge higher co- payments for emergency room visits, and may refuse to pay the entire bill if they determine that the illness or injury was not an emergency after all. As a result, patients are having second thoughts about rushing to the emergency room.

Just this week, the American Hospital Association reported that, for the first time in a decade, emergency room use in the United States has declined. In West Coast states, where health maintenance organizations dominate the market, usage fell a dramatic 13.9 percent from 1993 to 1994.

Williams' study is one of the few in the nation to examine emergency room costs, and perhaps the only significant study that has examined the actual cost of providing care based on the severity of the medical condition treated.

Emergency room charges are about double the actual costs, said Williams, because they tend to be the only place where people with no health insurance can get care -- and half the people who visit them do not pay their bills.

Emergency room physicians, who find themselves in a struggle to survive because of declining patient visits, were delighted with the findings.

"We've known this for a long time. We're tickled pink that a study has finally been done to prove it," said Dr. Gregory Henry, president of the American College of Emergency Physicians.

Henry contends that the study shows that emergency rooms can be cost-effective sources of routine medical care if resources are provided to cover the fixed costs of staffing for the true emergency. The problem, he said, is that health plan cost-cutters are driving paying patients away from emergency rooms, depriving them of income that can keep them open for either emergencies or minor ailments.

Patient advocates complain of denials of emergency room care. A federally commissioned study of Medicare HMO complaints found that 60 percent involved senior citizens who rushed to the hospital for conditions later challenged as true emergencies.

In the same issue of the New England Journal of Medicine, researchers at Oakland-based Kaiser Permanente reported that, a year after raising emergency room co- payments to between $25 and $35 from $5 to $10, emergency room use among 20,000 patients studied fell 15 percent with no detected increase in death rates.

"There was no evidence whatsoever of an adverse outcome," said Dr. Joe Selby, lead author of the Kaiser study.

The Kaiser study drew criticism from New England Journal deputy editor Dr. Robert Steinbrook, who noted that the increased fees were higher than the marginal cost of care cited by Williams.

Steinbrook said he is troubled by the fact that significant decreases in emergency room use were noted among groups with ailments classified as "often an emergency" -- those included head trauma, sickle cell crises, complications of pregnancy and chest pain. "By any standard, a substantial proportion of patients with these diagnoses should be evaluated in the emergency department."

Selby said critics misunderstood the study. Although emergency room use decreased among patients with conditions classified as "often an emergency," the study indicates that those with the most severe conditions went to the emergency room anyway.